Full Name

Phone *

Email *

Date of birth

Pronouns

Gender

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Session Type

Practitioner name

Recent Medications and Side Effects

Suicide / Self Harm

Current suicidal thoughts

Yes

No

Past suicidal thoughts

Yes

No

Current suicidal plan

Yes

No

Past suicide attempts

Yes

No

Current self-harm thoughts

Yes

No

Past self-harm thoughts

Yes

No

Past self-harm behaviour

Yes

No

If yes to any above, please provide details

Harm to Others

Current thoughts of harming someone else

Yes

No

Past homicidal thoughts or attempts

Yes

No

Harm to Others Details (If Yes)

Safety

Did the client feel safe at home

Yes

No

Is anyone hurting, threatening, or controlling the client

Yes

No

Are there any immediate safety concerns

Yes

No

Details of safety concern

Additional Practical Questions

Substance use

Yes

No

Has the client currently seen a psychiatrist

Yes

No

Is the Client under any legal, child protection, or court-related matter

Is there anything important you want the counsellor to know before meeting you

Presenting Concern

Why client came to the therapy

Client’s main concern in a few lines

When did this problem start

What was client hoping to get from therapy

Final Reviews

Presenting Problem

Session Number

Session Notes

Risk Review

Observations

Significant Triggers

Analysis

Techniques Used

Plan / Future Plan

Counsellor Reflection

Next Appointment

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If you are in immediate danger or experiencing a mental health crisis, please call 000 or contact Lifeline (13 11 14).
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